Cycle 1
Health 2024-12-19 · Fire 2024-12-19
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Ithaca, NY
Kendal At Ithaca
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2230 North Triphammer Road, Ithaca, NY
(607) 266-5300
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
45
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Kendal
Operator or chain grouping
Approved since
1996-02-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 5 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.40
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.77
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
2.33
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.18
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
1.05
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.62
CMS adjusted RN staffing hours
Adjusted total hours
5.52
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 41% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.01% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 4.44% · Lower 95% interval 6.16% |
| Discharge to community | 52.35% |
50.57%
1.8 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 51.52% · Lower 95% interval 41.24% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92% |
95.27%
3.3 pts worse
|
Numerator 23 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | 40.91% |
53.69%
12.8 pts worse
|
Numerator 9 · Denominator 22 |
| Discharge mobility score | 22.73% |
50.94%
28.2 pts worse
|
Numerator 5 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 78.68% |
42%
36.7 pts better
|
Numerator 214 · Denominator 272 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 12 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.3
0.4 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
91.2%
3.7 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 97.6% · Q3 97.4% · Q4 92.5% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.3% |
3.0%
3.3 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.3% · Q3 5.1% · Q4 10.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
18.5%
16.4 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.1% · Q3 2.8% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 12.8% |
6.1%
6.7 pts worse
|
5.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 20.0% · Q3 13.5% · Q4 5.6% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
13.5%
6.1 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 10.0% · Q3 8.1% · Q4 5.4% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
14.8%
5.2 pts worse
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 25.0% · Q4 22.7% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.5% |
15.1%
5.4 pts worse
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 31.4% · Q3 20.4% · Q4 11.1% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.8% |
15.5%
11.3 pts worse
|
14.9%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 24.3% · Q3 36.1% · Q4 11.1% · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.6%
0.7 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.4%
0.5 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
20.8%
1.7 pts worse
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 29.3% · Q3 19.2% · Q4 12.3% · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
6.9%
3 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.8% · Q3 5.2% · Q4 0.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
76.7%
11.2 pts better
|
81.7%
6.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 91.3% · Q3 86.2% · Q4 84.0% · 4Q avg 87.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.5% |
9.7%
7.8 pts worse
|
12.0%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 13.6% · Expected 8.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.2%
0.6 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
78.8%
4.5 pts better
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
20.6%
0.5 pts worse
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 13.6% · Expected 15.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-05 · Fire 2023-05-05
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-05-12 · Fire 2021-05-12
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-19
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-12-19
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-21
D · Potential for more than minimal harm
2024-12-19
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-02-18
D · Potential for more than minimal harm
2023-05-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-05
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-30
D · Potential for more than minimal harm
2021-05-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-07-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-12-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-12-19
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-12-19
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-12-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-12-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-02-14
D · Potential for more than minimal harm
2023-05-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-30
Penalties and ownership
What sits behind the stars
Ownership
Ackerman, Charles
Corporate Officer · Individual
Bradley, Ruth
Corporate Officer · Individual
Crane, William
Corporate Officer · Individual
Desnoes, Davina
Corporate Officer · Individual
Dugo, Peter
Corporate Officer · Individual
Ehren, Judith
Corporate Officer · Individual
Erickson, Mary Ann
Corporate Officer · Individual
Fretto, Megan
Operational/Managerial Control · Individual
Fretto, Megan
Corporate Director · Individual
Friends Services For The Aging
Operational/Managerial Control · Organization
Holochak, Austen
Operational/Managerial Control · Individual
Holochak, Austen
Corporate Director · Individual
Layton, Jeffrey
Corporate Officer · Individual
Mante, Laurie
Operational/Managerial Control · Individual
Mante, Laurie
Corporate Director · Individual
Mareane, Joe
Corporate Officer · Individual
Mathios, Alan
Corporate Officer · Individual
Nunley, Stephen
Corporate Officer · Individual
Pederson, Alan
Corporate Officer · Individual
Penoyer, Jeffrey
Corporate Officer · Individual
Rucker, Sonia
Corporate Officer · Individual
Sheppard, Christine
Corporate Officer · Individual
Skezas, Jacob
Operational/Managerial Control · Individual
Sommers, Gregory
Operational/Managerial Control · Individual
Sommers, Gregory
Corporate Officer · Individual
Staley, Lucy
Corporate Officer · Individual
Talty, Helen
Corporate Officer · Individual
Wilson, Donald
Corporate Officer · Individual
Youmans, Michael
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Cayuga Nursing And Rehabilitation Center
Ithaca, NY
2-star overall rating with 2-star inspections with $41,616 in total fines with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Beechtree Center For Rehabilitation And Nursing
Ithaca, NY
1-star overall rating with 2-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Oak Hill Rehabilitation And Nursing Care Center
Ithaca, NY
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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